Premature animals exposed to brief high tidal volume ventilation (from high PIP) develop lung injury, impaired gas exchange, and decreased lung compliance. Tactile stimulation should be limited to drying an infant and rubbing the back and soles of the feet.21,22 There may be some benefit from repeated tactile stimulation in preterm babies during or after providing PPV, but this requires further study.23 If, at initial assessment, there is visible fluid obstructing the airway or a concern about obstructed breathing, the mouth and nose may be suctioned. In preterm birth, there are also potential advantages from delaying cord clamping. This series is coordinated by Michael J. Arnold, MD, contributing editor. The research community needs to address the paucity of educational studies that provide outcomes with a high level of certainty. Nearly 10 percent of the more than 4 million infants born in the United States annually need some assistance to begin breathing at birth, with approximately 1 percent needing extensive resuscitation1,2 and about 0.2 to 0.3 percent developing moderate or severe hypoxic-ischemic encephalopathy.3 Mortality in infants with hypoxic-ischemic encephalopathy ranges from 6 to 30 percent, and significant morbidity, such as cerebral palsy and long-term disabilities, occurs in 20 to 30 percent of survivors.4 The Neonatal Resuscitation Program (NRP), which was initiated in 1987 to identify infants at risk of respiratory depression and provide high-quality resuscitation, underwent major updates in 2006 and 2010.1,57, A 1987 study showed that nearly 78 percent of Canadian hospitals did not have a neonatal resuscitation team, and physicians were called into a significant number of community hospitals (69 percent) for neonatal resuscitation because they were not in-house.8 National guidelines in the United States and Canada recommend that a team or persons trained in neonatal resuscitation be promptly available for every birth.9,10 Actual institutional compliance with this guideline is unknown. In a meta-analysis of 8 RCTs involving 1344 term and late preterm infants with moderate-to-severe encephalopathy and evidence of intrapartum asphyxia, therapeutic hypothermia resulted in a significant reduction in the combined outcome of mortality or major neurodevelopmental disability to 18 months of age (odds ratio 0.75; 95% CI, 0.680.83). Epinephrine should be administered intravenously at 0.01 to 0.03 mg per kg or by endotracheal tube at 0.05 to 0.1 mg per kg. Provide chest compressions if the heart rate is absent or remains <60 bpm despite adequate assisted ventilation for 30 seconds. Expert neonatal and bioethical committees have agreed that, in certain clinical conditions, it is reasonable not to initiate or to discontinue life-sustaining efforts while continuing to provide supportive care for babies and families.1,2,4, If the heart rate remains undetectable and all steps of resuscitation have been completed, it may be reasonable to redirect goals of care. The goal should be to achieve oxygen saturation targets shown in Figure 1.5,6, When chest compressions are indicated, it is recommended to use a 3:1 ratio of compressions to ventilation.57, Chest compressions in infants should be delivered by using two thumbs, with the fingers encircling the chest and supporting the back, and should be centered over the lower one-third of the sternum.5,6, If the infant's heart rate is less than 60 bpm after adequate ventilation and chest compressions, epinephrine at 0.01 to 0.03 mg per kg (1:10,000 solution) should be given intravenously. However, it may be reasonable to increase inspired oxygen to 100% if there was no response to PPV with lower concentrations. Exothermic mattresses have been reported to cause local heat injury and hyperthermia.15, When babies are born in out-of-hospital, resource-limited, or remote settings, it may be reasonable to prevent hypothermia by using a clean food-grade plastic bag13 as an alternative to skin-to-skin contact.8. A randomized trial showed that endotracheal suctioning of vigorous. monitored. Comprehensive disclosure information for writing group members is listed in Appendix 1(link opens in new window). PDF Neonatal Resuscitation Algorithm - American Heart Association The Neonatal Life Support Writing Group includes neonatal physicians and nurses with backgrounds in clinical medicine, education, research, and public health. Therapeutic hypothermia is provided under defined protocols similar to those used in published clinical trials and in facilities capable of multidisciplinary care and longitudinal follow-up. Preterm and term newborns without good muscle tone or without breathing and crying should be brought to the radiant warmer for resuscitation. In preterm infants, delaying clamping reduces the need for vasopressors or transfusions. Peer reviewer feedback was provided for guidelines in draft format and again in final format. Alternative compression-to-ventilation ratios to 3:1, as well as asynchronous PPV (administration of inflations to a patient that are not coordinated with chest compressions), are routinely utilized outside the newborn period, but the preferred method in the newly born is 3:1 in synchrony. The same study demonstrated that the risk of death or prolonged admission increases 16% for every 30-second delay in initiating PPV. In term and preterm newly born infants, it is reasonable to initiate PPV with an inspiratory time of 1 second or less. In resource-limited settings, it may be reasonable to place newly born babies in a clean food-grade plastic bag up to the level of the neck and swaddle them in order to prevent hypothermia. 1. An important point is that ventilation has been shown to be the most effective measure in neonatal resuscitation In a randomized trial, the use of mask CPAP compared with endotracheal intubation and mechanical ventilation in spontaneously breathing preterm infants decreased the risk of bronchopulmonary dysplasia or death, and decreased the use of surfactant, but increased the rate of pneumothorax. Infants 36 weeks or greater estimated gestational age who receive advanced resuscitation should be examined for evidence of HIE to determine if they meet criteria for therapeutic hypothermia. Intraosseous needles are reasonable, but local complications have been reported. It is reasonable to provide PPV at a rate of 40 to 60 inflations per minute. Copyright 2021 by the American Academy of Family Physicians. Other important goals include establishment and maintenance of cardiovascular and temperature stability as well as the promotion of mother-infant bonding and breast feeding, recognizing that healthy babies transition naturally. Breathing: Assist breathing with PPV if baby apneic, gasping, or bradycardic. No type of routine suctioning is helpful, even for nonvigorous newborns delivered through meconium-stained amniotic fluid. After an uncomplicated term or late preterm birth, it is reasonable to delay cord clamping until after the baby is placed on the mother, dried, and assessed for breathing, tone, and activity. A newly born infant in shock from blood loss may respond poorly to the initial resuscitative efforts of ventilation, chest compressions, and/or epinephrine. The exhaled carbon dioxide detector changes from purple to yellow with endotracheal intubation, and a negative result suggests esophageal intubation.5,6,25 Clinical indicators of endotracheal intubation, such as condensation in the tube, chest wall movement, or presence of bilateral equal breath sounds, have not been well studied. If the heart rate remains less than 60/min despite 30 seconds of adequate PPV, chest compressions should be provided. Aim for about 30 breaths min-1 with an inflation time of ~one second. The use of radiant warmers, plastic bags and wraps (with a cap), increased room temperature, and warmed humidified inspired gases can be effective in preventing hypothermia in preterm babies in the delivery room. Ninety percent of infants transition safely, and it is up to the physician to assess risk factors, identify the nearly 10 percent of infants who need resuscitation, and respond appropriately. Newly born infants who breathe spontaneously need to establish a functional residual capacity after birth.8 Some newly born infants experience respiratory distress, which manifests as labored breathing or persistent cyanosis. The potential benefit or harm of sustained inflations between 1 and 10 seconds is uncertain.2,29. One large retrospective review found that 0.04% of newborns received volume resuscitation in the delivery room, confirming that it is a relatively uncommon event. The 2 thumbencircling hands technique achieved greater depth, less fatigue, and less variability with each compression compared with the 2-finger technique. We thank Dr. Abhrajit Ganguly for assistance in manuscript preparation. If there is a heart rate response: Continue uninterrupted ventilation until the infant begins to breathe adequately and the heart rate is above 100 min-1. PPV may be initiated with air (21% oxygen) in term and late preterm babies, and up to 30% oxygen in preterm babies. Evidence suggests that warming can be done rapidly (0.5C/h) or slowly (less than 0.5C/h) with no significant difference in outcomes.1519 Caution should be taken to avoid overheating. Team debrieng. In one RCT and one observational study, there were no reports of technical difficulties with ECG monitoring during neonatal resuscitation, supporting its feasibility as a tool for monitoring heart rate during neonatal resuscitation. When providing chest compressions to a newborn, it may be reasonable to choose the 2 thumbencircling hands technique over the 2-finger technique, as the 2 thumbencircling hands technique is associated with improved blood pressure and less provider fatigue. Intrapartum suctioning is not recommended in infants born through meconium-stained amniotic fluid. Team briefings promote effective teamwork and communication, and support patient safety.8,1012, During an uncomplicated term or late preterm birth, it may be reasonable to defer cord clamping until after the infant is placed on the mother and assessed for breathing and activity. Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP. If resuscitation is required, heart rate should be monitored by electrocardiography as early as possible. It may be reasonable to administer a volume expander to newly born infants with suspected hypovolemia, based on history and physical examination, who remain bradycardic (heart rate less than 60/min) despite ventilation, chest compressions, and epinephrine. It is recommended to begin resuscitation with 21 percent oxygen, and increase the concentration of oxygen (using an air/oxygen blender) if oxygen saturation is low57 (see Figure 1). Three different types of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2020 process. One observational study describes the initial pattern of breathing in term and preterm newly born infants to have an inspiratory time of around 0.3 seconds. Consider pneumothorax. Administer epinephrine, preferably intravenously, if response to chest compressions is poor. Because evidence and guidance are evolving with the COVID-19 situation, this interim guidance is maintained separately from the ECC guidelines. Neonatal Resuscitation Study Guide - National CPR Association PDF 1. 2. 3. 4. - Enrollware No studies have examined PEEP vs. no PEEP when positive pressure ventilation is used after birth. This link is provided for convenience only and is not an endorsement of either the linked-to entity or any product or service. The recommended route is intravenous, with the intraosseous route being an alternative. Many current recommendations are based on weak evidence with a lack of well-designed human studies. Rapid and effective response and performance are critical to good newborn outcomes. In newborns who do not require resuscitation, delaying cord clamping for more than 30 seconds reduces anemia, especially in preterm infants. Babies who have failed to respond to PPV and chest compressions require vascular access to infuse epinephrine and/or volume expanders. For infants born at less than 28 wk of gestation, cord milking is not recommended. There are limited data comparing the different approaches to heart rate assessment during neonatal resuscitation on other neonatal outcomes. A new Resuscitation Quality Improvement (RQI) program for NRP focused on PPV will be . In term and late preterm newborns (35 wk or more of gestation) receiving respiratory support at birth, 100% oxygen should not be used because it is associated with excess mortality. The initiation of chest compressions in newborn babies with a heart rate less than 60/min is based on expert opinion because there are no clinical or physiological human studies addressing this question. 8. Outside the delivery room, or if intravenous access is not feasible, the intraosseous route may be a reasonable alternative, determined by the local availability of equipment, training, and experience. Every healthy newly born baby should have a trained and equipped person assigned to facilitate transition. ** After completing the initial steps of providing warmth, positioning the infant in the sniffing position, clearing the airway and evaluate the infant's response with the following: Therefore, identifying a rapid and reliable method to measure the newborn's heart rate is critically important during neonatal resuscitation. The usefulness of positive end-expiratory pressure during PPV for term infant resuscitation has not been studied.6 A recent study showed that use of mask continuous positive airway pressure for resuscitation and treatment of respiratory distress syndrome in spontaneously breathing preterm infants reduced the need for intubation and subsequent mechanical ventilation without increasing the risk of bronchopulmonary dysplasia or death.29 In a preterm infant needing PPV, a PIP of 20 to 25 cm H2O may be adequate to increase heart rate while avoiding a higher PIP to prevent injury to preterm lungs, and positive end-expiratory pressure may be beneficial if suitable equipment is available.6. During resuscitation, supplemental oxygen may be provided to prevent harm from inadequate oxygen supply to tissues (hypoxemia).4 However, overexposure to oxygen (hyperoxia) may be associated with harm.5, Term and late preterm newborns have lower shortterm mortality when respiratory support during resuscitation is started with 21% oxygen (air) versus 100% oxygen.1 No difference was found in neurodevelopmental outcome of survivors.1 During resuscitation, pulse oximetry may be used to monitor oxygen saturation levels found in healthy term infants after vaginal birth at sea level.3, In more preterm newborns, there were no differences in mortality or other important outcomes when respiratory support was started with low (50% or less) versus high (greater than 50%) oxygen concentrations.2 Given the potential for harm from hyperoxia, it may be reasonable to start with 21% to 30% oxygen. Ventilation should be optimized before starting chest compressions, with endotracheal intubation if possible. For newly born infants who are unintentionally hypothermic (temperature less than 36C) after resuscitation, it may be reasonable to rewarm either rapidly (0.5C/h) or slowly (less than 0.5C/h). In other situations, clamping and cutting of the cord may also be deferred while respiratory, cardiovascular, and thermal transition is evaluated and initial steps are undertaken. The writing groups then drafted, reviewed, and approved recommendations, assigning to each a Level of Evidence (LOE; ie, quality) and Class of Recommendation (COR; ie, strength) (Table(link opens in new window)).11. 1-800-AHA-USA-1 For every 30 seconds that ventilation is delayed, the risk of prolonged admission or death increases by 16%. Briefing has been defined as a discussion about an event that is yet to happen to prepare those who will be involved and thereby reduce the risk of failure or harm.4 Debriefing has been defined as a discussion of actions and thought processes after an event to promote reflective learning and improve clinical performance5 or a facilitated discussion of a clinical event focused on learning and performance improvement.6 Briefing and debriefing have been recommended for neonatal resuscitation training since 20107 and have been shown to improve a variety of educational and clinical outcomes in neonatal, pediatric, and adult simulation-based and clinical studies. Immediate, unlimited access to all AFP content, Immediate, unlimited access to this issue's content. Breathing is stimulated by gently rubbing the infant's back. Epinephrine is indicated if the heart rate remains below 60 beats per minute despite 60 seconds of chest compressions and adequate ventilation. Effective team behaviors, such as anticipation, communication, briefing, equipment checks, and assignment of roles, result in improved team performance and neonatal outcome. 0.5 mL Initiate effective PPV for 30 seconds and reassess the heart rate. Rate is 40 - 60/min. CPAP, a form of respiratory support, helps newly born infants keep their lungs open.